The latest informatics news and resources for local health departments and the public health community

Monthly Archives: October 2012

On October 15-16, in New York City, the WIRED Health Conference in association with the Robert Wood Johnson Foundation convened a conference to explore the challenges and opportunities of data-driven medicine. Featured speakers included geneticist Craig Venter, MIT’s Gig Hirsch, architect Michael Graves, and Intel’s Andy Grove. The subject was “Big Data”. The question was what is Big Data and what does it mean for health care providers and consumers?

The federal government has acknowledged this predicament and recently set aside more than $200 million to fund big data initiatives. Earlier this month, the National Science Foundation and the National Institutes of Health (NIH) awarded about $15 million to fund eight big data research projects. The awards will “ultimately help accelerate research to improve health — by developing methods for extracting important, biomedically relevant information from large amounts of complex data,” said NIH Director, Francis Collins in a press release. Other researchers are mining social media data to monitor the adverse effects of certain medications, and the NIH has also put the data from the 1000 Genomes Project in the cloud for other scientists to use.

The slate of sessions at the live-streamed WIRED conference showcased the many ways data can be deployed to improve health and wellness. Former Intel Chairman and CEO Andy Grove issued a call to arms to free healthcare data, making his case for radical price transparency in medicine. Another session at the conference spotlighted the work of Nicholas Christakis, director of the Human Nature Laboratory at Harvard University who said, “there’s a lot of talk about personal data, but even more important than individuals’ wellness behavior is the way that networks of people affect each other’s health.” Craig Venter imagined a future where you can download software, print a vaccine, inject it, and presto! Contagion averted.

Often local health departments (LHDs) are stretched in multiple directions. This is in large part due to the traditionally stove piped and programmatic funding of our organizations.

In our recent blog entry – A Vision For ePublic Health & Informatics – featuring Dr. David Ross Director of the Public Health Informatics Institute, LHDs are urged to have a visible and future vision for their informatics solutions. While that is very important, there is so much happening that folks are often asking, “Where should I start?” Well I believe you should attempt to find some focus. It is important to have an overarching vision for informatics so, as Dr. Ross says in the video, you can “be prepared to use emerging technologies when they come”. But I think once you have that broad vision, it is important to focus your resources on the project you will tackle right now. Of course you must be flexible as new opportunities and challenges may come along, but you have to practice good project management and can’t be too distracted in your approach.

This takes a very high level of executive sponsorship. You will have to devote personnel time, money, and may have to ration resources from other projects. Start with getting leadership to ask the organization to really reflect on the question “What is our business? “Or “What do we want our business to be?” With the competitive pressures of ACOs, FQHCs, HIEs, and other aspects of health care reform, it is more important than ever that local health departments know what our business is. Healthcare partners should know when it comes to [Enter Your Health Department Name Here], organizations should contract with you to provide certain services. These services could be things like Care Coordination, Home Health Visits, Specialty Care (HIV, STD, Dental, TB, Hepatitis, MCH), Primary Care for indigent populations, Surveillance, Environmental Health, Community Health Assessment, etc.

This understanding of your business will play a major part in defining where you should focus your informatics energy – but it isn’t everything. You now have to account for other pressures like technical infrastructure, workforce, Meaningful Use Requirements, funding etc. For example, do you have the right staff available for a project, can you receive Medicaid 90/10 funding through your state or Meaningful Use incentives, etc? And ask yourself, how long will this project take? Set realistic timelines, while being cognizant of any time limitations on your funding.

So now you know what your business focus is, what stressors are constraining you, and what resources may be available. You should be prepared to make an informed decision on where to focus your informatics efforts. Like a laser you can develop a meaningful resource for your department that can enhance the work you do and improve efficiencies in your agency. You can be a valued partner in the community and stake a claim on the work you do. You can meet or exceed expectations and that will likely produce new resources for your health department in the future.

Let me give you an example. Let’s say your overall vision for your health department involves creating a dashboard that provides real time information necessary for decision makers. It may be unlikely that you are able to build this tool all at once to serve every information need of the department. However, you do the assessment described above – survey your resources and environment to understand who is best suited to begin this project, which information is most needed right now, and which program may have some funding to support the project. Though you will build the infrastructure of the system to easily accommodate future data source additions, you will have to decide where to focus first. Let’s say you’ve decided to become a valued partner in the community by helping hospitals meet their IRS required community health assessments and you want the results of those assessments to be dynamically updated, near real time, and available to all pertinent decision makers in the health department, community, and hospitals. The IRS requirement means your service is likely valuable and may support a line of funding from hospitals or other community partners. You can now be focused on this project, get it accomplished in proper fashion – with Stakeholder participation and governance, project and risk management, and financing (see NACCHO’s tool – All Systems Go). In 12 to 18 months you’ll have a success and then be ready to focus on the next part of your vision.

Be visionary, be organized, be realistic, be focused, and you’ll be successful.

Dr. Farzad Mostashari, the National Coordinator for Health Information Technology, gave opening remarks at ONC’s Health Information Technology Policy Committee meeting. He discussed some of the latest happenings since the last HITPC meeting. This past interim, there were apparently several not so flattering commentaries in the newspapers. He described it as 3 acts in a play.

Act 1:

There were some opinions that ONC is acting as a cheerleader. A review of some cost benefit analysis was done on Meaningful Use incentives and said the data has not demonstrated any cost savings or real health benefit. Further these opinions apparently went on to say that the Meaningful Use effort is misguided and a waste of money. Another large criticism that came Dr. Mostashari’s way was that the government had not yet set any real standards for Health Information Exchange (HIE).

Dr. Mostashari responded by saying there were actually 31 cost studies done on this topic, and 27 out of 31 actually describe some cost benefit – not exactly the “rare exception” described. In addition, Dr. Mostashari asked the question, “if we increase A1C measures for diabetics and save 2 amputations – is it worth it?”

What we’re seeing is that health information technology (HIT) is an infrastructure that once in place, you can do any number of studies and improvements. The question isn’t if we need HIT infrastructure, but really the question is how do we do it and how do we maximize its use?

There are any number of stories of success, like the Minnesota diagnostic imaging scans that went electronic. Before the electronic infrastructure, the decision to approve a scan was convoluted and took 10 min or more. They asked the question, “could we use our electronic health record (EHR) for this approval process by coding the approval logic right into the system?” Once they did, they saw a dramatic decrease in inappropriate and duplicate scans, and it took only 10 seconds for approval.

As for the assertion that “there are no standards”, Dr. Mostashari pointed out that many use cases are now beginning to arrive at consensus standards precisely because of Meaningful Use. It has taken some time, but stage 2 will show some really big changes in the near future. He pointed out that many of the standards are cataloged at the Meaningful Use Stage 2 Standards-Hub.

Act 2:

A series of articles in several news papers around the country came out regarding billing. They found that the decade before meaningful use (2000 – 2009), there was an association between higher severity codes and payments. The implication was that this meaningful use government incentive program to encourage adoption of electronic health records may have had an unintended consequence of increasing both the number of requests and cost of severity codes. Actually, Dr. Mostashari said, it is unclear if many things were simply under coded and now are captured or if there is a great deal of fraud. It is also not clear what the final and total impact is on cost. It is entirely possible that admission levels have improved despite these changes in coding. More substantially, meaningful use was a conscious effort to move systems away from documentation and billing and toward patient centered care coordination and population health. “If we continue to pay for documentation and more visits, that is exactly what we’ll get.”

Farzad mentioned that 76 percent of plans and medical homes expect to be in an Accountable Care Organization (ACO) pay model. You simply can’t do a better job of measuring care without access to good information.

In addition, immutable health logs, a byproduct of meaningful use, help to enforce against fraud. If care is documented that didn’t actually occur, then that is bad care and illegal and we take that very seriously.

We also just heard about results of the open notes project (sponsored by RWJ). Something like 99% of consumers and 100% of providers in the project want this practice of secure and full access to medical records for all appropriate parties to continue to be offered. Again this sort of practice will go a long way to discover out and out fraud.

With all of that said, it is incumbent upon us the HIT policy committee to take another look at documentation for medical purposes and offer guidelines and policies for what is good medical documentation. We need to find out what would be good EHR functionality and what is just “over the line”. Too much documentation just for higher billing codes, bypassing the audit log, or skipping record amendments where we can clarify should be considered in that discussion.

Act 3:

There is real change beginning to occur on the ground. But don’t expect this to be a one shot success. It is and always has been a staged approach. The first stage is collecting structured data. The second stage is thinking about population health and data sharing. The third stage is really getting to the meaningful use of electronic medical records. One commenter said, “let’s be patient here, you can’t ask a two year old to do six year old tricks.”

The largest ever study of diabetes is underway through electronic EHR data and initial findings indicate remarkable improvement in patient care. We owe it to practitioners and vendors to set ambitious goals, provide guidance, and maybe even a little bit of cheerleading.

A couple of years ago, I was presented with the opportunity to serve on the local Wichita Health Information Exchange Board and the Kansas Electronic Health Advisory Council at the state level. Those opportunities coupled with a grant from the Kansas Health Foundation to review how the state immunization registry would work with the health information exchange (HIE), thrust me into the unknown world of health information technology (HIT) and HIE.

My observation during this period of learning is that connecting to the HIE is not on the radar of many local health departments. Leadership is needed at state, local and regional levels and if you’re not sure how to get started, I’d suggest beginning with the questions below.

1) Is connecting to the HIE part of my Health Department’s strategic plan?

All local health departments are responsible for monitoring communicable diseases and protecting the community from health threats. At the very least, exchanging data with community health partners about clients with reportable diseases is a reason to participate in the system.

2) Is my Health Department at the HIE table?

You can start by checking with your state health department for information about the state HIE board. Find out which Regional Extension Center serves your jurisdiction. Check with your State Association of County and City Health Officials for an HIE committee or workgroup. Check with your local and state medical societies to identify where leadership is coming from. Ask if you can participate on some level, perhaps through a committee or representing local health departments on a board.

3) Has my Health Department figured out what is needed from the HIE and how to get it?

In Kansas, an HIE Committee has been formed through the Kansas Association of Local Health Departments. The local health department representative on the State HIE Board and I chair this committee. We have focused on education and awareness of new developments in the state until recently. At our last meeting we decided to engage a consultant who could assist us with the process of answering the following questions:

What do you need information for?

Assessment

Surveillance

Analysis and investigation

Case management

Care coordination

What are short, intermediate and long-term needs?

How often and when is the information desired?

Individual client vs. aggregate level de-identified? Geo-coded?

What kind of information might be available from the HIE?

Patient

Laboratory

Pharmacy

What is the best way to have access to this information? Choices include through:

Electronic Medical Record (EMR)

Clinic management system

Linked clinic management system and EMR

Partially linked clinic management system and EMR with toggle

Direct through HIE

Intermediary like the state health department

What plans does the state health department have for maintaining or beginning a registry linkage to the HIE?

I urge you to get involved and utilize NACCHO’s resources to guide you through the health IT maze. Once the HIE is fully functional, LHDs will have a new opportunity to demonstrate value to the public health system. Now is the time to take a seat at the table.

NOTICE

The views expressed here reflect the views of the bloggers alone, and do not necessarily reflect
the views of any of their organizations. In particular, the views expressed here do not necessarily reflect
those of the National Association of County and City Health Officials.

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